How Indiana's State Plan Amendment could limit ABA services come April

 

SOUTH BEND, Ind.-- Indiana's Family and Social Services Administration (FSSA) is looking to cut Medicaid spending by targeting Applied Behavior Analysis (ABA) therapy, the leading treatment for people with severe autism.

The proposed State Plan Amendment, or SPA, originally aimed to put a lifetime restriction for ABA to three years per patient. This was to be retroactive, so any patient who already received three or more years of ABA would be done with treatment. It also capped ABA to 30 hours per week per patient.

"That was pretty scary, to think of April 1 of this year, if you had already been in treatment for three years, you qualified for nothing else. So a lot of families, a lot of providers were very, very nervous," said Kristin Wier, chief program officer for therapy services at LOGAN Community Services.

However, after a public input period that ended on Feb. 14, the FSSA updated the SPA to somewhat loosen the restrictions.

"We're really trying to get a lot of answers because right now, we still don't have those," Wier said.

The updated SPA is no longer retroactive, so the three-year clock would start on April 1 for all patients.

"This gives us some transition time," Wier said. "We can really assess medical necessity, we can work with the families on the best transition plan."

The SPA now offers tiers of service depending on the autism severity. The weekly cap ranges from 30 to 38 hours per week depending on whether the individual is diagnosed with level one, two, or three of autism spectrum disorder. Families would need to determine what level their loved one qualifies for.

While the changes are an improvement from the original SPA, Wier said, she still does not support the broad Medicaid changes.

"We had some people state this was a win or a victory. I wouldn't yet call it that," she said. "Having limitations on a lifelong pervasive disability or disorder always gives me pause or a little bit of fear because at any time in someone's life, their symptoms could change."

She said putting a time limit on treatment makes no sense for a lifelong disorder or disability.

After the three-year cap, some can still qualify for limited-hour, behavior-specific ABA with prior authorization.

"Limitations always give me a little pause because it's not based on the individual, it's based on a law," she said.

These changes to Medicaid and ABA go into effect April 1 pending approval from the state's Centers for Medicare and Medicaid Services.

At the same time, Indiana Governor Mike Braun is still looking into ABA spending with another executive order. This one essentially forms a task force to find solutions to contain the rising cost of ABA without compromising the quality of care.

Braun cited the soaring Indiana Medicaid payments, from more than $14 million in 2017 to $120 million in 2019. These payments are expected to increase by another factor of five over the next year, he said.

Wier said this is partly from improved access.

"That was because we have more resources in Indiana now, we have more people who are able to get diagnostics now. Families are seeing the value of ABA therapy they're seeing how life-changing it was for their loved ones," she said. "So, more families were seeking out the treatment so more people were being covered over the last several years."

Braun also cited an audit of the state's ABA payments from 2019 and 2020, which found more than $56 million in improper Medicaid ABA payments.

Caps to ABA services, the fastest-growing Medicaid expenditure, are one way the governor hopes to curb improper government Medicaid spending.